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A man with a chest mass

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Q1: What is the interpretation of the biopsy specimen (see p 629)?

The specimen is an excision biopsy of the tumour. Cut section of the mass shows a variegated appearance with areas of haemorrhage, cystic changes, and necrosis. The histological findings are those of metastatic adenocarcinoma.

Q2: What are the different types of rib tumours?

The bone metastases is either osteoclastic (often squamous cell carcinoma), osteolytic (prostate carcinoma, poorly differentiated adenocarcinoma, and breast carcinoma in young patients), intratrabecular, or of mixed type.

Q3: What is the mode of spread to the rib?

Bone marrow metastases is either via the transpulmonary route, or the vertebral venous system—the latter results in metastases to the spine.1 The frequency of bone metastases via the vertebral venous plexus without pulmonary metastases is 30% for carcinoma of the prostate, 10.4% for uterus, 7.4% for breast, and 3.5% for stomach.1

Discussion

The patient has a rib secondary from an obscure primary. Detailed gastrointestinal tract evaluation and chest evaluation were non-contributory.

Moriwaki has described different types of rib tumours.1 These can be further classified as benign or malignant—the latter are often secondaries from a primary in the lung (35%).2

Micrometastases from gastro-oesophageal malignancy has been reported.1,3 Oesophagogastric malignancy results in micrometastases of ribs in 88% and in the iliac crest in 15%.3 These are independent of the histological type, nodal status, and neoadjuvant therapy.3 Macrometastases is less common.

Yang et al described three sonographic patterns on cross section of abnormal ribs4; ultrasound guided biopsy yields a 100% result without any complications and is an ideal method of confirming the diagnosis.

Management depends on the histopathology and is often directed to the primary site. Large tumours, as in our case, requires surgical resection followed by chemotherapy. The patient is doing well six months after the resection. Failure to find the primary tumour poses problems in management. Yet it remains controversial whether the prognosis improves when the primary tumour is identified by intensive diagnostic search as in the present case.5 Overall the prognosis is poor.

Final diagnosis

Adenocarcinoma of the rib.

References

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